Investigation into ways to prevent or reduce deaths of children by drowning

The Western Australian Ombudsman has an important responsibility to review certain child deaths, identify patterns and trends arising from these reviews and make recommendations about ways to prevent or reduce child deaths. Of the child death notifications received by the Ombudsman since commencing the child death review responsibility, 42 have been deaths of children by drowning.

To undertake the investigation, the Ombudsman conducted an extensive literature review, comprehensively considered 34 deaths of children by drowning notified to the office of the Ombudsman over a six-year investigation period, surveyed all local governments in Western Australia (to which the office received a 99 per cent response rate), selected five local governments for further investigation, collected and analysed comprehensive information regarding the number of private swimming pools in local government districts and the quality of the swimming pool barrier inspection process, engaged with the (now) Department of Mines, Industry Regulation and Safety, the Building Commissioner, the Department of Health, the (now) Department of Local Government, Sport and Cultural Industries and relevant non-government and not-for-profit organisations.

The Ombudsman also collected and analysed de-identified information regarding the number of children admitted to a hospital or who attended an emergency department at a hospital following a non-fatal drowning incident. The Ombudsman found that 258 children were admitted to a hospital and 2,310 children attended an emergency department at a hospital following a non-fatal drowning incident.

The Ombudsman has found that a range of work has been undertaken by the Department of Mines, Industry Regulation and Safety and the Building Commissioner to administer their respective responsibilities in relation to swimming pool safety. The Ombudsman also found that there is important further work that should be done. This work is detailed in the findings of this report. It will be critical that this work is undertaken with strong cooperation between the Department of Mines, Industry Regulation and Safety, the Building Commissioner, local governments and other key stakeholders, including intra-agency, inter-agency and cross-sectoral arrangements – this is the most efficient and effective way to achieve positive change.

Arising from the findings, the Ombudsman has made 25 recommendations about ways to prevent or reduce deaths of children by drowning. The Ombudsman is very pleased that the Department of Mines, Industry Regulation and Safety and the Building Commissioner have agreed to these recommendations. In keeping with the Ombudsman’s commitment to Parliament to ensure Parliament is informed about the implementation of the Ombudsman’s investigations, the Ombudsman will actively examine the steps taken to give effect to the recommendations and report the results of this examination to Parliament in 2018.

The Ombudsman notes his appreciation to the Department of Mines, Industry Regulation and Safety, the Building Commissioner and local governments – their cooperation through the investigation has been particularly positive and reflects their genuine willingness to engage in review, reflection and improvement.

The death of a child by drowning is a tragedy – for a child’s life lost and for the parents, families and communities that have been personally affected by the tragic death. It is the Ombudsman’s sincere hope that the investigation will, through its research and analysis and its recommendations, make a meaningful contribution to the prevention and reduction of this tragic loss of life.

A report on giving effect to the recommendations arising from the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

The Western Australian Ombudsman undertakes an important responsibility to review family and domestic violence fatalities. Arising from this work, the Ombudsman identified the need to undertake a major own motion investigation into issues associated with violence restraining orders (VROs) and their relationship with family and domestic violence fatalities.

On 19 November 2015, the Ombudsman tabled the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities (FDV Investigation Report) in the Western Australian Parliament. Through that investigation, the Ombudsman found that a range of work had been undertaken by state government departments and authorities to administer their relevant legislative responsibilities, including their responsibilities arising from the Restraining Orders Act 1997. The Ombudsman also found, however, that there is important further work that should be done. This work, detailed in the findings of the FDV Investigation Report, includes a range of important opportunities for improvement for state government departments and authorities, working individually and collectively, across all stages of the VRO process.

The Ombudsman also found that Aboriginal Western Australians are significantly overrepresented as victims of family violence, yet underrepresented in the use of VROs. Following from this, the Ombudsman identified that a separate strategy, specifically tailored to preventing and reducing Aboriginal family violence, should be developed. This strategy should actively invite and encourage the full involvement of Aboriginal people in its development and be comprehensively informed by Aboriginal culture.

Furthermore, the FDV Investigation Report identified nine key principles for state government departments and authorities to apply when responding to family and domestic violence and in administering the Restraining Orders Act 1997. Applying these principles will enable state government departments and authorities to have the greatest impact on preventing and reducing family and domestic violence and related fatalities.

Arising from the findings in the FDV Investigation Report, the Ombudsman made 54 recommendations to four government agencies about ways to prevent or reduce family and domestic violence fatalities. Each agency agreed to these recommendations.

Importantly, the Ombudsman also indicated that the Ombudsman's office would actively monitor the implementation of these recommendations and report to Parliament on the results of this monitoring. Accordingly, the Ombudsman has now provided Parliament ‘A report on giving effect to the recommendations arising from the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities’.

The Ombudsman is pleased that in relation to all of the recommendations, the relevant state government departments and authorities have either taken steps, or propose to take steps (or, in some cases, both) to give effect to the recommendations. In no instance has the office found that no steps have been taken, or are proposed to be taken, to give effect to the recommendations.

It is particularly pleasing that, in giving effect to the recommendations, important improvements have been achieved when compared to the findings identified in the FDV Investigation Report.

This report sets out the steps taken, or proposed to be taken, to give effect to the recommendations arising from the FDV Investigation Report, however, the work of the Ombudsman's office in ensuring that the recommendations of the investigation are given effect does not end with the tabling of this report.

The Ombudsman's office will continue to monitor, and report on, whether steps continue to be taken to give effect to the recommendations arising from the FDV Investigation Report. The next such report will be provided in the Ombudsman's office’s 2016-17 Annual Report.

Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

The Western Australian Ombudsman undertakes an important responsibility to review family and domestic violence fatalities. Arising from this work, the Ombudsman identified the need to undertake a major own motion investigation into issues associated with violence restraining orders (VROs) and their relationship with family and domestic violence fatalities.

To undertake the investigation, in addition to an extensive literature review and stakeholder engagement, the office of the Ombudsman collected and analysed a comprehensive set of de-identified state-wide data relevant to family and domestic violence and examined 30 family and domestic violence fatalities notified to the Ombudsman.

The Ombudsman has found that a range of work has been undertaken by state government departments and authorities to administer their relevant legislative responsibilities, including their responsibilities arising from the Restraining Orders Act 1997. The Ombudsman has found, however, that there is important further work that should be done. This work, detailed in the findings of this report, includes a range of important opportunities for improvement for state government departments and authorities, working individually and collectively, across all stages of the VRO process. The Ombudsman has also found that Aboriginal Western Australians are significantly overrepresented as victims of family violence, yet underrepresented in the use of VROs. Following from this, the Ombudsman identified that a separate strategy, specifically tailored to preventing and reducing Aboriginal family violence, should be developed. This strategy should actively invite and encourage the full involvement of Aboriginal people in its development and be comprehensively informed by Aboriginal culture.

Furthermore, this investigation has identified nine key principles for state government departments and authorities to apply when responding to family and domestic violence and in administering the Restraining Orders Act 1997. Applying these principles will enable state government departments and authorities to have the greatest impact on preventing and reducing family and domestic violence and related fatalities.

Arising from the findings of the investigation, the Ombudsman has made 54 recommendations to four government agencies about ways to prevent or reduce family and domestic violence fatalities. The Ombudsman is very pleased that each agency has agreed to these recommendations and has, more generally, been highly co-operative, responsive and positively engaged with the Ombudsman’s investigation.

Importantly, the office of the Ombudsman will actively monitor the implementation of these recommendations and report to Parliament the results of this monitoring.

In undertaking this investigation, the Ombudsman acknowledges the employees of state government departments and authorities, including police officers and child protection workers, as well as non-government organisations, who, on a day to day basis, work to keep victims safe and hold perpetrators accountable.

Finally, the Ombudsman acknowledges, and expresses deepest sympathy to, the families and communities who have been affected by family and domestic violence fatalities in Western Australia. Throughout this report the Ombudsman has sought to ensure that the victims of family and domestic violence are heard, including through a number of case studies titled ‘A victim’s voice’.

Investigation into ways that State government departments and authorities can prevent or reduce suicide by young people

The Western Australian Ombudsman reviews certain child deaths, identifies patterns and trends arising from these reviews and makes recommendations about ways to prevent or reduce child deaths.

Of the child death notifications received by the Ombudsman's office since the child death review function commenced, nearly a third related to children aged 13 to 17 years old. Of these children, suicide was the most common circumstance of death, accounting for nearly forty per cent of deaths. Furthermore, and of serious concern, Aboriginal children were very significantly over-represented in the number of young people who died by suicide. For these reasons, the Ombudsman decided to undertake a major own motion investigation into ways that State government departments and authorities can prevent or reduce suicide by young people.

The Ombudsman has found that State government departments and authorities have already undertaken a significant amount of work that aims to prevent and reduce suicide by young people in Western Australia, however, there is still more work to be done. The Ombudsman has found that this work includes practical opportunities for individual agencies to enhance their provision of services to young people. Critically, as the reasons for suicide by young people are multi-factorial and cross a range of government agencies, the Ombudsman has also found that this work includes the development of a collaborative, inter-agency approach to preventing suicide by young people. In addition to the findings and recommendations, the comprehensive level of data and analysis contained in this report will, the Ombudsman believes, be a valuable new resource for government departments and authorities to inform their planning and work with young people. In particular, the analysis suggests this planning and work target four groups of young people that the Ombudsman has identified.

Arising from this investigation, the report makes 22 recommendations to four government agencies about ways to prevent or reduce suicide by young people. The Ombudsman is pleased that each agency has agreed to these recommendations and has, more generally, been highly co-operative and positively engaged with our investigation.

Investigation into ways that State Government departments can prevent or reduce sleep-related infants deaths

The Western Australian Ombudsman reviews certain child deaths, identifies patterns and trends arising from these reviews and makes recommendations designed to prevent or reduce child deaths.

In undertaking the child death review function, the Ombudsman identified a need to undertake an investigation into the number of deaths that have occurred after infants have been placed to sleep. In this report, these deaths are called ‘sleep-related infant deaths’.

The investigation has principally involved the Department of Health but also involved the Department for Child Protection and the Department for Communities. The objectives of the investigation were to analyse all sleep-related infant deaths notified to the Ombudsman's office, consider the results of the analysis in conjunction with the relevant research and practice literature, undertake consultation with key stakeholders and, from this analysis, research and consultation, recommend ways the departments can prevent or reduce sleep-related infant deaths.

The investigation has found that the Department of Health has undertaken a range of work to contribute to safe sleeping practices in Western Australia, however, there is still important work to be done. This work particularly includes establishing a comprehensive statement on safe sleeping that will form the basis for safe sleeping advice to parents, including advice on modifiable risk factors, that is sensitive and appropriate to both Indigenous and culturally and linguistically diverse communities and is consistently applied state-wide by health care professionals and non-government organisations at the antenatal, hospital-care and post-hospital stages. This statement and concomitant policies and practices should also be adopted, as relevant, by the Department for Child Protection and the Department for Communities.

The investigation has also found that a range of risk factors were prominent in sleep-related infant deaths reported to the Ombudsman’s office. Most of these risk factors are potentially modifiable and therefore present opportunities for the departments to assist parents, grandparents and carers to modify these risk factors and reduce or prevent sleep-related infant deaths.

Arising from this investigation, the report makes 23 recommendations about ways to prevent or reduce sleep-related infant deaths. The Ombudsman is pleased that each department has agreed to these recommendations and has, more generally, been highly co-operative and positively engaged with the Ombudsman’s investigation.

Planning for children in care: An Ombudsman’s own motion investigation into the administration of the care planning provisions of the Children and Community Services Act 2004

The Western Australian Ombudsman reviews investigable child deaths, identifies patterns and trends arising from these reviews and makes recommendations for improvement designed to prevent or reduce investigable child deaths.

In undertaking this role, the Ombudsman identified a need to undertake an investigation of planning for children in the care of the Chief Executive Officer of the Department for Child Protection – a particularly vulnerable group of children in the community.

The investigation involved the Department for Child Protection, the Department of Health and the Department of Education and considered, among other things, the relevant provisions of the Children and Community Services Act 2004, the internal policies of each of these departments and the recommendations arising from the Review of the Department for Community Development undertaken by Ms Prudence Ford.

In the five years since the introduction of the Children and Community Services Act 2004, these three agencies have worked cooperatively to operationalise the requirements of the Act. In short, the investigation found significant and pleasing progress on improved planning for children in care had been achieved, however, there was still work to be done.

The findings of the investigation and the 23 recommendations for improvement are detailed in the Ombudsman’s report Planning for children in care: An Ombudsman’s own motion investigation into the administration of the planning provisions of the Children and Community Services Act 2004.

The Management of Personal Information - good practice and opportunities for improvement

Personal information can be defined as information that identifies an individual or could identify that individual. State Government agencies properly require individuals to provide a range of personal information about themselves in order to deliver services, carry out law enforcement, administer regulations and perform other statutory functions. In short, effective and efficient service delivery, including the protection of the well-being of individuals and groups of people, may require an agency to disclose or share personal information it has collected.

Inappropriate use of personal information is, however, as a matter of principle, wrong. Practically, it can compromise an individual’s privacy leading to undesirable outcomes.

Alleged inaccuracy and inappropriate use of personal information is a source of complaint to the Ombudsman’s office. These complaints provided an important base of evidence to suggest that the Ombudsman should review the management of personal information by State Government agencies.

The findings of the review are detailed in the Ombudsman’s report The Management of Personal Information – Good Practice and Opportunities for Improvement.

In June 2010, the Ombudsman’s office reported on a survey of all public authorities within the Ombudsman's jurisdiction to gain an overview of their complaint handling practices. This was the third such survey conducted by the office over the past ten years. The survey questionnaire asked organisations to assess their complaint handling processes and practices against a series of principles based on, and consistent with, the Public Sector Commissioner’s Circular 2009-27: Complaints Management and the Australian Standard (AS ISO 10002-2006: Customer Satisfaction - Guidelines for Complaints Handling in Organisations). The survey addressed ten principles for complaint handling, as set out below:

The findings of the survey are detailed in the Ombudsman's Report 2009-10 Survey of Complaint Handling Practices in the Western Australian State and Local Government Sectors.